Teaching health care students about disability within a cultural competency context

Dismantling Ableism in Undergraduate Medical Education: Promising Practices in Disability-Conscious Training

The healthcare workforce in the United States does not provide the same standard of care for people with disabilities as for nondisabled people. Many academic medical institutions do not routinely offer disability-conscious medical training, and many clinicians and medical educators feel ill-equipped to incorporate anti-ableist learning goals into their curricula. Drawing on a critical review of the literature and interviews with medical educators, representatives of professional organizations, and disability advocates, this article presents promising practices for disability-conscious undergraduate medical education. Disability-conscious education, which is grounded in the insights of disability studies and disability rights and justice frameworks, is distinguished from disability-specific education, which may not extend beyond biomedical models of disability. First, we define current approaches to teaching about disability, highlighting limitations and opportunities for further development. We then identify and analyze approaches to teaching about disability that support the development of disability consciousness among learners. With attention to both curricular format and theoretical frameworks, we offer concrete approaches that medical schools can take to equip students with the knowledge, attitudes, skills, and practices they need to provide equitable care for patients with disabilities.

Framework for an interprofessional experience addressing health and disability for health professional students

BACKGROUND AND PURPOSE

A Health and Disabilities Interprofessional Education (IPE) course was implemented to join three healthcare disciplines together to collaboratively plan, implement, and reflect on professional roles and responsibilities. The goal and purpose of this course was to create an advancement of interprofessional education and practice within health science professions early in their students' programs utilizing innovative teaching methods working directly with individuals with disabilities.

EDUCATIONAL ACTIVITY AND SETTING

72 students were assigned to interprofessional teams of 10-11 people. Through asynchronous and synchronous learning activities, student teams worked together to plan and conduct community-based client interviews.

FINDINGS

Quantitative and qualitative evaluation methods were used to explore the impact of interprofessional experiential learning experiences. Qualitative data showed a greater awareness and understanding of the different roles and responsibilities in interprofessional teams as well as a greater appreciation for the value of interacting with persons with disabilities (PWD) during their training. Quantitative data showed a significant change in students' understanding of their roles and responsibilities as a member of an interprofessional team, their confidence with working with PWD in a future healthcare capacity, as well as their understanding of how the social determinants of health may influence the healthcare experience of a PWD.

SUMMARY

Interprofessional education and experiential learning opportunities are good ways to facilitate "real" patient care experiences and team roles and responsibilities. This enables healthcare students to practice communication, build relationships, and understand the lived experience of their patients.

The study of ableism in population health: a critical review

Over the past three decades, health equity has become a guiding framework for documenting, explaining, and informing the promotion of population health. With these developments, scholars have widened public health's aperture, bringing systems of oppression sharply into focus. Additionally, some researchers in disability and health have advocated for utilizing socially grounded frameworks to investigate the health of disabled people. Yet, naming ableism, much less operationalizing it for the empirical study of health, remains scant. This paper critically reviews the study of ableism as a social determinant of disabled people's health within population health research. First, we provide an orientation to the present state of this literature by looking to the past. We briefly trace a history of traditional approaches to studying disability and health and alternatives that have emerged from critiques of the individualized lens that has dominated this work. Next, we delineate the operation of ableism across social levels. We characterize how ableism has been studied in population health in terms of levels of analysis (intrapersonal, interpersonal, institutional, and structural) and measures of interest. To conclude, we discuss hinderances to and promising avenues toward population health research that advances health equity for disabled people.

Disability competency training in medical education

PURPOSE

Lack of health care providers' knowledge about the experience and needs of individuals with disabilities contribute to health care disparities experienced by people with disabilities. Using the Core Competencies on Disability for Health Care Education, this mixed methods study aimed to explore the extent the Core Competencies are addressed in medical education programs and the facilitators and barriers to expanding curricular integration.

METHOD

Mixed-methods design with an online survey and individual qualitative interviews was used. An online survey was distributed to U.S. medical schools. Semi-structured qualitative interviews were conducted via Zoom with five key informants. Survey data were analyzed using descriptive statistics. Qualitative data were analyzed using thematic analysis.

RESULTS

Fourteen medical schools responded to the survey. Many schools reported addressing most of the Core Competencies. The extent of disability competency training varied across medical programs with the majority showing limited opportunities for in depth understanding of disability. Most schools had some, although limited, engagement with people with disabilities. Having faculty champions was the most frequent facilitator and lack of time in the curriculum was the most significant barrier to integrating more learning activities. Qualitative interviews provided more insight on the influence of the curricular structure and time and the importance of faculty champion and resources.

CONCLUSIONS

Findings support the need for better integration of disability competency training woven throughout medical school curriculum to encourage in-depth understanding about disability. Formal inclusion of the Core Competencies into the Liaison Committee on Medical Education standards can help ensure that disability competency training does not rely on champions or resources.

Educating health science students about disability: Teachers' perspectives on curricular gaps

BACKGROUND

People living with disabilities are significantly more likely than their peers to find health professionals' skills and facilities inadequate. The 66th World Health Assembly called for better health care for people with disabilities including more inclusive health services and a stronger focus on professional training.

OBJECTIVE

To explore how teachers at a New Zealand university perceived the need, approaches, and systemic challenges to enhance disability education for health professionals in training.

METHODS

Qualitative analysis of interviews with 11 key informants teaching in population health, medicine, nursing, pharmacy, and optometry training programmes. Transcribed interview recordings were analysed using a general inductive approach.

RESULTS

The participants described a range of teaching approaches that they used to increase disability awareness among their students. However, these were largely ad hoc individually driven initiatives reflecting personal interests. Participants identified a critical need to develop and implement a systematic, integrated approach to enhance disability education particularly from a social justice perspective among students in health disciplines. Engaging people with lived experience of disability in teaching and course design, and senior administrative commitment were identified as necessary to address current gaps in education.

CONCLUSIONS

In order to develop a health professional workforce competent to respond to the needs of people with disabilities, greater attention is required at a strategic level to enhance the profile of disability education in health curricula. Meaningful engagement of people with disability and senior leadership commitment are critical components that can enable effective progression of this agenda.

Disability & Diversity studies as a professional basis for diversity-aware education and training in medicine

The "Disability and Diversity Studies" (DDS) are research fields which, similar to social work, deal with social inclusion and exclusion processes. Dimensions of disability and diversity can lead to disadvantages and inequalities in the individual life and social coexistence of people. The DDS examine these inequalities and identify intersectional relationships between diversity categories. The concept of intersectionality opens up the view of the restriction of diversities, which can lead to the intensification of inequalities and multiple discriminations: e. g., in the case of being a woman and member of an ethnic minority. The starting point is therefore not the difference category per se, but the intersection of several categories [5]. This knowledge of categorizing classification and exclusion in their intersectionality is fundamental for the dissolution of social, societal, political and economic inequality. The DDS bachelor's program at the Carinthia University of Applied Sciences, which combines Disability and Diversity Studies, focuses on these research areas and develops practical solutions. In medical education and training, too, it is essential that teachers and students, but also patients, recognise the complex interrelationships of divergences in medical practice and the resulting stigma that must be removed. The DDS can serve as a basis for taking these interrelationships into account, for incorporating creative approaches to solutions and a diversity-sensitive attitude into the doctor-patient relationship and medical treatment. For example, the first and so far only World Report on Disability from 2011 noted a still existing negative infiltration of doctor-patient-interactions through stigmatization of persons with disabilities and deviations. Misunderstandings, lack of knowledge and wrong presettings can endanger the treatment [32]. In order to create the framework conditions for an appropriate consideration of diversity and disability in the program, it is necessary to impart six core competencies to prospective physicians [20]: If possible, this should always be designed in the respective training courses of all health care professions in a patient-centred manner, across all occupational groups and under the premise "nothing for us without us" [1]. This corresponds to the principles of Disability Studies.

Health professionals' views on maternity care for women with physical disabilities: a qualitative study

BACKGROUND

During pregnancy, childbirth and puerperium, women receive care from a range of health professionals, particularly midwives. To assess the current situation of maternity care for women with physical disabilities in Austria, this study investigated the perceptions and experiences of health professionals who have provided care for women with disabilities during pregnancy, childbirth and postpartum.

METHODS

The viewpoints of the participating health professionals were evaluated by means of semistructured interviews followed by an inductive qualitative content analysis of the interview transcripts, as proposed by Mayring.

RESULTS

Four main categories emerged from the inductive content analysis: (i) structural conditions and accessibility, (ii) interprofessional teamwork and cooperation, (iii) action competence, and (iv) diversity-sensitive attitudes. According to the participating health professionals, the structural conditions were frequently not suitable for providing targeted group-oriented care services. Additionally, a shortage of time and staff resources also limited the necessary flexibility of treatment measures in the care of mothers with physical disabilities. The importance of interprofessional teamwork for providing adequate care was highlighted. The health professionals regarded interprofessionalism as an instrument of quality assurance and team meetings as an elementary component of high-quality care. On the other hand, the interviewees perceived a lack of action competence that was attributed to a low number of cases and a corresponding lack of experience and routine. Regarding diversity-sensitive attitudes, it became apparent that the topic of mothers with physical disabilities in care posed challenges to health professionals that influenced their natural handling of the interactions.

CONCLUSION

The awareness of one's own attitudes towards diversity, in the perinatal context in particular, influences professional security and sovereignty as well as the quality of care of women with disabilities. There is a need for optimization in the support and care of women with physical disabilities during pregnancy, childbirth and puerperium.

Disabled people say 'Nothing about us without us'

BACKGROUND

This study explored disability community representatives' perspectives on why and how health professional education could be strengthened to address the prevalent challenges in health care experienced by disabled people.

METHODS

A total of 14 people from the disability community (disabled people, caregivers and disability advocates) in Auckland, New Zealand, participated in three focus groups moderated by a disabled community researcher. Audiorecordings were transcribed and analysed thematically to characterise broad themes.

FINDINGS

Participants described many barriers to health care experienced by disabled people, with service providers' inadequate knowledge of disability issues being a key contributor. Participants viewed educational approaches incorporating disabled peoples' diverse lived realities as critical to improving health system responses to these inequities. They recommended broadening concepts and teaching methods to shift common deficit framing of disability, engaging disabled people to develop and deliver curricula, improving communication, and promoting empathic provider-patient partnerships in care. Study participants strongly advocated inclusive participatory approaches across training pathways using assistive and multimedia technologies that optimise the engagement of disabled people and reduce respondent burden.

DISCUSSION

Disability community participants urged strengthening health professional training to address the prevalent inadequacies of health systems in responding to disabled people's needs. They viewed a greater awareness of the lived realities of disabled people and critical consciousness to overcome barriers to care as essential attributes of a competent workforce. These findings indicate the need to engage, empower and work in partnership with disabled people to develop reflexive health professional curricula. Core competencies should be considered mandatory given the increasing prevalence of disability globally. This study explored disability community representatives' perspectives on why and how health professional education could … address … challenges in health care experienced by disabled people.

Completing Disability Forms Efficiently and Accurately: Curriculum for Residents

INTRODUCTION

The completion of a patient's disability assessment form (DAF) is a task expected of family and internal medicine physicians. Residency curricula rarely address this task. Thus, some residents are reluctant to conduct functional assessments because of inadequate training, the time required to conduct such an exam, and fear of jeopardizing the doctor-patient relationship. This article describes a curricular intervention to prepare residents to complete a focused functional capacity assessment during a 30-minute office visit.

METHODS

Developing the curriculum for DAF completion involved a literature review, conducting needs assessment interviews, and a review of existent residency training materials. Instructional strategies included lecture, panel discussions, and demonstrations. The learner evaluation strategies were knowledge tests, direct observation of residents, and a review of disability cases with an expert panel consisting of federally certified Social Security Administration workers. This work represents information gained from four pilot tests.

RESULTS

The residents' knowledge scores increased significantly. Knowledge of state, federal, and employer disability programs increased as well as their ability to distinguish sedentary, light, medium, and heavy work capacity when related to patients' medical conditions. All the residents could perform the assessment, but none of them were confident that they could complete the DAF in a 30-minute office visit. This was an expected outcome.

CONCLUSIONS

It is possible to teach family and internal medicine residents the knowledge and skills required to determine their patients' functional capacity as it relates to a specific problem. By applying what they have learned to their patients, they will eventually be able to complete a DAF during a 30-minute office visit. Residency programs are encouraged to incorporate a functional assessment curriculum.

Nurse Educator Attitudes Toward People With Disabilities

AIM

As educators strongly influence the attitudes of their students, the purpose of this study was to determine nurse educator attitudes toward people with disabilities.

BACKGROUND

Inadequate education of health professionals is a known barrier to care for people with disability. Continuing calls for improved education of health professionals compel an assessment of nurse educator attitudes.

METHOD

This was a cross-sectional, correlational web-based survey of nurse educators (n = 126). Nurse educator attitudes were analyzed using descriptive statistics, analysis of variance, and multiple regression analysis.

RESULTS

Nurse educators held discriminatory attitudes toward people with disabilities, though most preferred a biopsychosocial model of disability. Forty-four percent lacked knowledge of disability-related aims, objectives, or outcomes within the curriculum.

CONCLUSION

To advance equity in health care, nurse educators must confront personal bias and teach competent care of people with disabilities.

Access to and Satisfaction with Prenatal Care Among Pregnant Women with Physical Disabilities: Findings from a National Survey

BACKGROUND

Previous qualitative studies suggest that women with physical disabilities face disability-specific barriers and challenges related to prenatal care accessibility and quality. This study aims to examine the pregnancy and prenatal care experiences and needs of U.S. mothers with physical disabilities and their perceptions of their interactions with their maternity care clinicians.

MATERIALS AND METHODS

We conducted the first survey of maternity care access and experiences of women with physical disabilities from 37 states. The survey was disseminated in partnership with disability community agencies and via social media and targeted U.S. women with a range of physical disabilities who had given birth in the past 10 years. The survey included questions regarding prenatal care quality and childbirth and labor experiences.

RESULTS

A total of 126 women with various physical disability types from 37 states completed the survey. Almost half of the respondents (53.2%) reported that their physical disability was a big factor in their selection of a maternity care provider and 40.3% of women reported that their prenatal care provider knew little or nothing about the impact of their physical disability on their pregnancy. Controlling for maternal demographic characteristics and use of mobility equipment, women who reported that their prenatal care provider lacked knowledge of disability and those who felt they were not given adequate information were more likely to report unmet needs for prenatal care.

CONCLUSIONS

The findings from this study suggest the need for training and education for clinicians regarding the prenatal care needs of women with physical disabilities.

Obstetric clinicians' experiences and educational preparation for caring for pregnant women with physical disabilities: A qualitative study

BACKGROUND

Women with physical disabilities (WPD) experience major barriers to care during pregnancy. Lack of education about disability in health professionals' education is a pervasive barrier to quality care. In an effort to explore this issue, this study examined the issue from the perspective of obstetric clinicians who provide care to WPD.

OBJECTIVE

This qualitative descriptive study explored perspectives of obstetric clinicians who provide perinatal care for WPD to inform the educational preparation of clinicians to care for women with disabilities.

METHOD

We contacted 33 obstetric clinicians who care for pregnant WPD. Thirteen obstetricians and one nurse midwife participated in semi-structured telephone interviews. Interview transcriptions were content analyzed to identify initial themes. Investigators discussed and revised the themes as additional transcripts were reviewed and new themes were identified.

RESULTS

Themes identified from transcript analyses included: lack of education at any level including during postgraduate residency and fellowship on care of pregnant WPD, unplanned career pathway, educating other clinicians, and positive and negative experiences providing obstetrical care to women with physical disability. Several clinicians provided this care because of requests from other clinicians and did not begin their careers with the goal of providing obstetric care to women with physical disabilities. None had received formal education or training including during their residencies or fellowships. The clinicians described very rewarding experiences caring for WPD.

CONCLUSIONS

The experiences reported by this study's participants suggest the need to include disability in undergraduate and postgraduate education and training to improve obstetric care to WPD.

Nurturing constructive change that works: a critical theory-informed model for transforming health service psychologists’ views of people with disabilities

We have been developing and refining a disability training exercise for health service psychologists that is ever more effective at encouraging lasting change in the way students regard disabilities and the people who live with those disabilities. Although research suggests that simulation exercises tend to be ineffective at creating long-term attitude change in participants, quantitative and qualitative results indicate our exercise, composed of a simulation followed by debriefing and reflection, helps professionals better understand some of the challenges people with disabilities daily face, and how those challenges can affect their well being. We found this combination is more likely to yield long-term changes than any of these approaches alone. This paper is not principally the description of a pedagogical technique, but instead is an examination of how the combination of simulation, debriefing, and reflective journaling may challenge taken-for-granted assumptions about disabilities, e.g., that disabilities transform individuals into a different kind of human being (with either superhuman powers or as object of pity) instead of seeing these individuals as ordinary people facing extraordinary, and often society-created obstacles. One frequent call of Critical Theorists is to challenge those things we take for granted. Social and cultural structures create specific viewpoints and thus problematizing the apparent is necessary for understanding of, and emancipation from, potentially oppressive social structures. Inspired by this call to render the taken-for-granted as problematic, the exercise we describe creates inversions of performer/audience, professional/student, and scientist/researcher positions. In each of these inversions, the role of the objective observer is denied and the student is invited to engage in his or her own evaluative and potentially transformative experience. Through each of these inversions, different realities can be more readily utilized by thoughtful students to render problematic some of the dominant views about people with disabilities. To make this case, we utilize both qualitative and quantitative methods. The students’ own words, captured in their journals before and after the exercise, are examined in comparison with program goals and features. The weight of the evidence is impressive, indicating that the combination of simulation, debriefing and journaling reflection are effective at creating a space in which change of attitudes does occur.

Barriers to providing maternity care to women with physical disabilities: Perspectives from health care practitioners

BACKGROUND

Women with physical disabilities are known to experience disparities in maternity care access and quality, and communication gaps with maternity care providers, however there is little research exploring the maternity care experiences of women with physical disabilities from the perspective of their health care practitioners.

OBJECTIVE

This study explored health care practitioners' experiences and needs around providing perinatal care to women with physical disabilities in order to identify potential drivers of these disparities.

METHODS

We conducted semi-structured telephone interviews with 14 health care practitioners in the United States who provide maternity care to women with physical disabilities, as identified by affiliation with disability-related organizations, publications and snowball sampling. Descriptive coding and content analysis techniques were used to develop an iterative code book related to barriers to caring for this population. Public health theory regarding levels of barriers was applied to generate broad barrier categories, which were then analyzed using content analysis.

RESULTS

Participant-reported barriers to providing optimal maternity care to women with physical disabilities were grouped into four levels: practitioner level (e.g., unwillingness to provide care), clinical practice level (e.g., accessible office equipment like adjustable exam tables), system level (e.g., time limits, reimbursement policies), and barriers relating to lack of scientific evidence (e.g., lack of disability-specific clinical data).

CONCLUSION

Participants endorsed barriers to providing optimal maternity care to women with physical disabilities. Our findings highlight the needs for maternity care practice guidelines for women with physical disabilities, and for training and education regarding the maternity care needs of this population.

Introduction to Disability and Health for Preclinical Medical Students: Didactic and Disability Panel Discussion

INTRODUCTION

Millions of American patients have a disability, and their health care outcomes depend on the attitudes of their health care providers towards persons with disabilities. Overly negative health care provider attitudes lead to significant misunderstandings about what it means to have a disability, inappropriate assumptions, and poor care. However, very few medical schools teach about disability.

METHODS

We developed a preclinical medical student curriculum that addresses the complexity of disability, focusing on health care disparities and bias. Our curriculum was designed with significant input from people with disabilities and was constructed from their perspective. In addition to didactic and discussion sessions on disability history, models of disability, and health disparities, we include a discussion panel with community members who have a disability.

RESULTS

The curriculum has been effective at promoting discussion and is well received by students. When rating the relevance to future clinical practice, students gave the curriculum an average of 3.9 on a 5-point Likert scale (1 = poor, 5 = excellent). The majority of students commented that the community involvement in the session was the most meaningful aspect.

DISCUSSION

It is possible to integrate community-driven discussions on the social context of disability into traditional medical school preclinical curricula, and students find it valuable to their education.

Stigma and Developmental Disabilities in Nursing Practice and Education

Individuals with developmental disabilities (DD) experience stigma, discrimination, and barriers, including access to appropriate health care, that restrict their ability to be equal participants in society. In this study, underlying contexts, assumptions, and ways of acting are investigated that perpetuate inequalities and pejorative treatment toward those with disabilities. Several nurse researchers and educators suggest specific content for, or approaches to, education about DD. Critical pedagogy that employs cultural competency and a disability studies' framework to guide curriculum and course development will allow assumptions underlying common health care practices that oppress and "other" people with disabilities to be exposed and changed.

Contextual analysis of gynaecological care provided to women with physical disability

This is a theoretical-reflective study that aimed to analyze the contexts associated with gynaecological care for women with physical disabilities. Discussion consisted of contextual analysis according to Hinds, Chaves and Cypress, leading to four interconnected layers: immediate, specific, general and metacontext. Analysis showed that gynaecological assistance to clients with physical disabilities is influenced by attitudinal, structural, financial and informational barriers. Other influential issues are social beliefs and stigmas and the persistence of a biomedical model, which is hegemonic in this type of assistance. Therefore, gynaecological care must be valued based on the holistic paradigm offered by a transdisciplinary team in order to provide quality care to women with physical disabilities.